MEDICARE: VILLAGE PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY41506	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0578508	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1508887555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE PHARMACY

Provider Business Mailing Address
First Line	:	3137 S HOOVER ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-3196
Country	:	US
Telephone Number	:	213-749-2346
Fax Number	:	213-749-5270

Provider Business Practice Location Address
First Line	:	3137 S HOOVER ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-3196
Country	:	US
Telephone Number	:	213-749-2346
Fax Number	:	213-749-5270

Authorized Official
Title or Position	:	PIC
Name	:	JAY IN PARK
Credential	:
Telephone Number	:	213-749-2346

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	05/07/2012

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Directions to “VILLAGE PHARMACY ” Practice Location

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